Identifying Gaps in Pelvic Pain Education: A Scoping Review and Structured Analysis of Obstetrics and Gynecology Training Milestones.

OBJECTIVE: Several clinical practice guidelines on the evaluation and management (EM) of chronic pelvic pain (CPP) have been published; however, it is not known whether obstetrics and gynecology (OBGYN) educational milestones are aligned with current practice recommendations. Therefore, this scoping review and structured analysis aims to identify gaps between clinical guidelines for the EM of CPP and OBGYN training milestones published by educational authorities like the Accreditation Council for Graduate Medical Education (ACGME) and the AAGL. DATA SOURCES: The literature search was performed in MEDLINE, PubMed Central, and Bookshelf on the PubMed interface from January 2018 to September 2022. Peer-reviewed publications were included if they were a systematic review of recent practice guidelines and focused on female CPP. Publications that focused on a single pelvic pain condition or focused on a specific treatment were excluded. METHODS OF STUDY SELECTION: Two reviewers extracted the data and appraised the study quality following the Critical Appraisal Skills Programme Checklist for systematic reviews. Four articles met inclusion criteria for thematic analysis. A reflexive thematic analysis via the inductive approach was performed to develop clinical themes common to all review articles and presumed important in the EM of CPP. Pelvic pain experts and Delphi methodology was used to assess validity and relevance of each theme in OBGYN training. Validated themes were used in a strengths weaknesses opportunities threats (SWOT) analysis of the ACGME and the AAGL Milestones used for training OBGYN residents and fellows. A SWOT analysis is an organizational tool used to analyze processes in terms of strengths, weaknesses, opportunities for improvement, and threats to implementing a potential change. TABULATION, INTEGRATION, AND RESULTS: Twelve clinical themes were conceptualized and achieved ≥ 90% consensus as being important in the EM of CPP. Clinical themes pertained to pathophysiology, biopsychosocial approach, trauma-informed care, history and physical examination, diagnostic testing, multimodal/multidisciplinary management, pain education, and medical and surgical management. SWOT analysis showed that the ACGME Milestones lacked milestones specific to CPP, while the AAGL Milestones had 6 CPP-focused competencies with multiple milestones. Milestones on trauma-informed care and application of biopsychosocial assessment were notably absent. CONCLUSION: OBGYN educational milestones published by the ACGME and the AAGL are not yet aligned with current clinical guidelines for the EM of CPP.

Chronic Pelvic Pain in Women: A Review.

IMPORTANCE: Chronic pelvic pain (CPP) is a challenging condition that affects an estimated 26% of the world's female population. Chronic pelvic pain accounts for 40% of laparoscopies and 12% of hysterectomies in the US annually even though the origin of CPP is not gynecologic in 80% of patients. Both patients and clinicians are often frustrated by a perceived lack of treatments. This review summarizes the evaluation and management of CPP using recommendations from consensus guidelines to facilitate clinical evaluation, treatment, improved care, and more positive patient-clinician interactions. OBSERVATIONS: Chronic pelvic pain conditions often overlap with nonpelvic pain disorders (eg, fibromyalgia, migraines) and nonpain comorbidities (eg, sleep, mood, cognitive impairment) to contribute to pain severity and disability. Musculoskeletal pain and dysfunction are found in 50% to 90% of patients with CPP. Traumatic experiences and distress have important roles in pain modulation. Complete assessment of the biopsychosocial factors that contribute to CPP requires obtaining a thorough history, educating the patient about pain mechanisms, and extending visit times. Training in trauma-informed care and pelvic musculoskeletal examination are essential to reduce patient anxiety associated with the examination and to avoid missing the origin of myofascial pain. Recommended treatments are usually multimodal and require an interdisciplinary team of clinicians. A single-organ pathological examination should be avoided. Patient involvement, shared decision-making, functional goal setting, and a discussion of expectations for long-term care are important parts of the evaluation process. CONCLUSIONS AND RELEVANCE: Chronic pelvic pain is like other chronic pain syndromes in that biopsychosocial factors interact to contribute and influence pain. To manage this type of pain, clinicians must consider centrally mediated pain factors as well as pelvic and nonpelvic visceral and somatic structures that can generate or contribute to pain.

Opioid Prescription Usage after Benign Gynecologic Surgery: A Prospective Cohort Study.

STUDY OBJECTIVE: To compare the amount of opioids (tablets and morphine milligram equivalents [MMEs]) prescribed by physicians and used by patients after benign gynecologic surgery. DESIGN: Prospective cohort study. SETTING: Tertiary center: main hospital operating room and outpatient surgery center. PATIENTS: Women undergoing benign gynecologic surgery. INTERVENTIONS: Major and minor gynecologic surgeries. MEASUREMENTS AND MAIN RESULTS: The surgery groups were minor laparoscopy (Minor), major minimally invasive (Major), and laparotomy (Laparotomy). Demographic, medical, and surgical data were abstracted from electronic medical records. On postoperative day (POD) 7, women completed a telephone survey describing pain levels, prescription use, and satisfaction with pain control. Patients who continued to use opioids for pain relief were surveyed on POD 14. If use continued, patients were surveyed again on POD 28. The primary outcome was amount of opioid prescribed compared with opioid used. Of 193 screened participants 172 were enrolled (89%), and data were analyzed for 154 (90%): 59 (38%) Major, 71 (56%) Minor, and 24 (16%) Laparotomy. The median number of tablets and MMEs prescribed was lowest for the Minor group (Minor, 24 tablets; Major, 30 tablets; Laparotomy, 30 tablets [p <.01]; Minor, 150 MMEs; Major, 225 MMEs; Laparotomy, 225 MMEs [p = .01]). We found no difference in the number of tablets (Minor, 8; Major, 8; Laparotomy, 9; p = .77) or MMEs used (Minor, 45 MMEs; Major, 45 MMEs; Laparotomy, 55 MME; p = .81) between the groups. On POD 7 there was no difference in median numerical rating scale pain scores (Minor, 3; Major, 2; Laparotomy, 2; p = .07) or satisfaction with analgesia on POD 7 (p = .44), 14 (p = .87), and 28 (p = .18). Patients with prior chronic pain used more total amounts of opioids (68 MME vs 30 MME, p <.01) and were more likely to require opioid refill (odds ratio, 10.4; 95% confidence interval, 1.3-83.6) compared with those without a similar history. CONCLUSION: In this cohort, gynecologic surgeons prescribed nearly 3 times more opioid tablets and MMEs than was used by patients despite patients reporting similar levels of pain after minor and major surgeries.

Perioperative pain management: an update for obstetrician-gynecologists.

The opioid epidemic in the United States is unprecedented and continues to worsen. Many opioid abusers obtain their pills through legitimate prescriptions, directly or indirectly, from a medical provider. While practitioners have a responsibility to treat pain, it is now becoming clear that aggressive opioid prescription practices contribute to an epidemic of abuse. The medical community has to balance the unintended consequences of opioid misuse and abuse with the need to provide adequate pain control. Additionally, providers are being held accountable by the legal system and professional organizations for their prescribing practices. Responsible use of opioids is paramount and pain control does not supersede safety. Effective and safe pain management requires that providers perform risk assessments, understand medication risks, avoid excessive reliance on opioids, and adequately monitor and educate patients. Obstetricians and gynecologists are uniquely positioned to influence pain management practices as primary care providers and surgeons who regularly manage both acute and chronic pain conditions. Therefore, the objective of this publication was to familiarize obstetricians and gynecologists with contemporary concepts in pain management and summarize recent guidelines in a manner that is applicable to our specialty. We focus on perioperative pain management, which is the time period immediately before, during, and after surgery. Topics reviewed include proper risk assessment to evaluate a patient's potential for poor pain control or development of chronic pain or misuse of opioids; multimodal pain management with nonpharmacological, nonopioid alternatives, safe opioid-use strategies; education and documentation; and special considerations for women, veterans, and lactation concerns.

Patterns in Vulvodynia Treatments and 6-Month Outcomes for Women Enrolled in the National Vulvodynia Registry-An Exploratory Prospective Study.

BACKGROUND: Vulvodynia is a poorly characterized condition with multiple treatment options that have been described as largely ineffective in research settings. AIM: To describe treatment patterns in women enrolled in the National Vulvodynia Registry and determine if there is an association between selected treatments and patient-reported outcomes such as pain, sexual function, and psychological distress after 6 months of treatment. METHODS: Participants completed questionnaires on general medical history and patient-reported outcomes using the short-form McGill Pain Questionnaire, the Female Sexual Function Index, the Short Form-12 quality-of-life questionnaire, the Coping Strategies Questionnaire, and the State-Trait Anxiety Inventory. The evaluation also included pain sensitivity assessment of the vaginal mucosa using a cotton-tipped applicator and the vaginal muscles using a single-digit. In this prospective cohort study, all measurements were collected at baseline and again at 6 months after treatment. OUTCOMES: Type of treatment, number of treatments, self-reported pain intensity, dyspareunia, and pain-related psychological distress measures are reported at baseline and 6 months. RESULTS: Of 344 women enrolled, 282 received treatment; 78 different treatments were identified and categorized by type (eg, topical, oral, physical therapy) and number. The most commonly used treatments were topical (85%, n = 241), physical therapy (52%, n = 147), and oral medications (45%, n = 128). Notably, 73% of participants received ≥2 treatments. There was no association between type or number of treatments and patient characteristics. At 6 months, women reported improvements in general pain (P = .001), pain during intercourse (P = .001), catastrophizing (P = .000), and anxiety (P = .000). The Short Form-12 quality-of-life questionnaire showed improvements in physical limitations (P = .024), emotional limitations (P = .003), well-being (P = .025), and social function (P = .010). However, all domains of the Female Sexual Function Index indicated worsening in sexual function (P = .000) except for pain. CLINICAL TRANSLATION: Multi-modal treatments were most commonly used in clinical practice and improvements in patient-reported outcomes such as quality of life, distress, and pain were noted; however, participants who returned at 6 months continued to report poor sexual function. CONCLUSIONS: Strengths include a prospective and long-term study design that evaluated women in clinical settings. Limitations include a high rate of loss to follow-up for certain measures and inability to evaluate efficacy of individual treatments. In a setting where women were receiving highly specialized care, we found wide variation in the type and number of treatments used to treat vulvodynia. Despite this heterogeneity in treatment selection, women reported significant improvements in all study measures except sexual function. Lamvu G, Alappattu M, Witzeman K, et al. Patterns in Vulvodynia Treatments and 6-Month Outcomes for Women Enrolled in the National Vulvodynia Registry-An Exploratory Prospective Study. J Sex Med 2018;15:705-715.

Non-opioid pain management in benign minimally invasive hysterectomy: A systematic review.

BACKGROUND: Less postoperative pain typically is associated with a minimally invasive hysterectomy compared with a laparotomy approach; however, poor pain control can still be an issue. Multiple guidelines exist for managing postoperative pain, yet most are not specialty-specific and are based on procedures that bear little relevance to a minimally invasive hysterectomy. OBJECTIVE: The purpose of this study was to determine whether there is enough quality evidence within the benign gynecology literature to make non-opioid pain control recommendations for women who undergo a benign minimally invasive hysterectomy. STUDY APPRAISAL AND SYNTHESIS METHODS: We queried PubMed, ClinicalTrials.gov, and Cochrane databases using MeSH terms: "postoperative pain," "perioperative pain," "postoperative analgesia," "pain management," "pain control," "minimally invasive gynecologic surgery," and "hysterectomy." A manual examination of references from identified studies was also performed. All PubMed published studies that involved minimally invasive hysterectomies through November 9, 2016, were included. This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies were restricted to benign minimally invasive hysterectomies evaluating non-opioid pharmacologic therapies. Primary outcomes included amount of postoperative analgesics consumed and postoperative pain scores. Two reviewers independently completed an in-depth evaluation of each study for characteristics and results using an established database, according to inclusion/exclusion criteria. A risk assessment was performed, and a quality rating was assigned with the use of the Cochrane Collaboration's Grades of Recommendation, Assessment, Development and Evaluation approach. RESULTS: Initially 1155 studies were identified, and 24 studies met all inclusion criteria. Based on limited data of varying quality, intravenous acetaminophen, anticonvulsants and dexamethasone demonstrate opioid-sparing benefits; ketorolac shows mixed results in laparoscopic hysterectomies. Paracervical blocks provide pain-reducing benefits in vaginal hysterectomies. CONCLUSIONS: Convincing conclusions are difficult to draw because of the heterogeneous and contradictory nature of the literature. There is a clear need for more high-quality research that will evaluate each medication type for posthysterectomy pain control.

Catechol-O-methyltransferase gene polymorphism and vulvar pain in women with vulvodynia.

BACKGROUND: The underlying causes of vulvar pain in women with vulvodynia remain poorly understood. Catechol-O-methyltransferase, an enzyme that metabolizes catecholamines, is a neuromodulator that is involved with perception and sensitivity to pain. The catechol-O-methyltransferase gene is polymorphic, and a single nucleotide polymorphism is associated with low activity and heightened pain sensitivity. The variant allele that encodes this polymorphism commonly is called the "L allele" because of its low enzyme activity as opposed to the normal H (high activity) allele. OBJECTIVE: The methionine-containing catechol-O-methyltransferase protein coded by the L allele results in elevated catecholamine levels, reduced inactivation of the dopaminergic and adrenergic systems, and increased sensitivity to pain. This polymorphism not only may decrease the pain threshold in response to acute pain but also may facilitate the development of chronic pain. Therefore, the objective of our study was to assess whether a variation in the catechol-O-methyltransferase genotype is involved in increased pain sensitivity in women with vulvodynia. STUDY DESIGN: We conducted a prospective cohort study. METHODS: Buccal swabs were collected from 167 white women with vulvodynia and 107 control subjects; the DNA was tested for a single nucleotide polymorphism at position 158 (rs4680) in the catechol-O-methyltransferase gene. RESULTS: Women with vulvodynia had a marginally increased, yet not significant, prevalence of the catechol-O-methyltransferase genotype that is associated with high activity of the coded protein: 32.9% in the women with vulvodynia, as opposed to 21.5% in the control subjects (odds ratio, 1.80; 95% confidence interval, 1.02-3.15). Subgrouping the cases based on pain frequency revealed that the elevated occurrence of this catechol-O-methyltransferase genotype was present in 40.6% of the subset of women who experienced pain only with sexual intercourse vs only 21.5% of control subjects (odds ratio, 2.50; 95% confidence interval, 1.27-4.93). Also, women with primary vulvodynia had a significantly higher prevalence of the H allele than did the control subjects (62.9% vs 48.1%; odds ratio, 1.82; 95% confidence interval, 1.05-3.17). CONCLUSION: Increased pain sensitivity in women with vulvodynia is not due to a genetically determined low catechol-O-methyltransferase enzyme activity. Other mechanisms may account for alterations in catechol-O-methyltransferase activity in women with pain that is limited to intercourse or primary vulvodynia that contributes to pain sensitivity.

Wound Infiltration With Extended-Release Versus Short-Acting Bupivacaine Before Laparoscopic Hysterectomy: A Randomized Controlled Trial.

STUDY OBJECTIVE: To evaluate if preincision infiltration with extended-release liposomal bupivacaine provides improved overall pain relief compared with 0.25% bupivacaine after laparoscopic or robotic-assisted hysterectomy. DESIGN: A single-center double-masked randomized controlled trial (Canadian Task Force Classification I). SETTING: A tertiary-care community hospital. PATIENTS: Patients recruited from July 2015 through January 2016. Sixty-four patients were randomized, and 59 were analyzed for the primary outcome. INTERVENTIONS: Women scheduled to undergo multiport laparoscopic or robotic-assisted total hysterectomy for benign indications were randomized to receive preincision infiltration with undiluted liposomal bupivacaine or 0.25% bupivacaine. MEASUREMENTS AND MAIN RESULTS: The primary outcome was overall average pain intensity by numeric rating scale (0-10) using the Brief Pain Inventory (BPI) via telephone survey on postoperative day (POD) 3. A sample size of 28 per group (N = 56) was planned to detect a 30% change in pain scores. Secondary outcomes were overall average and worst numeric pain scores on PODs 1, 2, and 14; pain scores in hospital; BPI pain interference scores; and total opioid use. There were no demographic differences between the 2 groups. For the primary outcome, we found a decrease in the average (p = .02) pain scores on POD 3 in the liposomal bupivacaine group. We also found a decrease in worst pain scores on POD 2 (p = .03) and POD 3 (p = .01). There were no differences in pain scores while in the hospital or on POD 1 or POD 14. There were no differences in BPI pain interference scores, opioid use, or reported adverse effects. CONCLUSION: For laparoscopic and robotic-assisted multiport hysterectomies, there is evidence of decreased average postoperative pain with liposomal bupivacaine compared with 0.25% bupivacaine for port-site analgesia on POD 3, but no difference in opioid use or measures of functioning.

The Evidence-based Vulvodynia Assessment Project. A National Registry for the Study of Vulvodynia.

OBJECTIVE: To create a national registry for the study of vulvodynia in order to enhance classification of vulvodynia based on multiple phenotypic domains such as pain characteristics, clinical examination, sexual function, psychological functioning, and distress. STUDY DESIGN: Methodology for this prospective cohort registry was institutional review board approved and implemented at 8 enrollment sites starting in 2009. Women underwent gynecologic evaluation and pressure sensory testing for assessment of pain sensitivity in the vaginal mucosa and vaginal muscles. Psychometric questionnaires were used to assess self-described pain, distress, sexual function, and quality of life. RESULTS: More than 300 women were enrolled and 176 charts were analyzed. This cohort had a median age of 29 years and median pain duration of 25.5 months. A total of 84% of participants were previously or currently sexually active in spite of pain. The most common pain comorbidities reported by the women were migraines (34%), chronic pelvic pain (22%), and irritable bowel syndrome (20%). Anxiety affected 41% of the cohort. More than 90% presented with localized vestibular pain, and 90% had muscular examination abnormalities. CONCLUSION: A national registry for the study of vulvodynia was established with successful enrollment of participants at 8 sites. In addition to the cotton swab evaluation for vulvar allodynia, women with vulvar chronic pain should also be routinely screened for musculoskeletal dysfunction, emotional distress with specific emphasis on anxiety, and comorbid pain conditions.

Managing chronic pelvic pain following reconstructive pelvic surgery with transvaginal mesh.

In 2001, the US Food and Drug Administration (FDA) approved the first transvaginal mesh kit to treat pelvic organ prolapse (POP). Since the introduction of vaginal mesh kits, some vaginal meshes have been associated with chronic pelvic pain after reconstructive pelvic floor surgery. Pelvic pain results in between 0 % and 30 % of patients following transvaginal mesh placement. Common causes of chronic pelvic pain include pelvic floor muscle spasm, pudendal neuralgia, and infection. Paucity of data exists on the effective management of chronic pelvic pain after pelvic reconstructive surgery with mesh. We outline the management of chronic pelvic pain after transvaginal mesh placement for reconstructive pelvic floor repair based on our clinical experience and adaptation of data used in other aspects of managing chronic pelvic pain conditions.

Presence of endometriosis and chronic overlapping pain conditions negatively impacts the pain experience in women with chronic pelvic-abdominal pain: A cross-sectional survey.

BACKGROUND: Evidence of overlap between endometriosis and chronic pain conditions is emerging; however, little is known about how the pain experience differs based on the presence or absence of endometriosis. OBJECTIVES: In a sample of women reporting chronic pelvic-abdominal pain (CPP), the aim of this study was to characterize differences in pain symptomatology between women with and without endometriosis and to examine the influence of chronic overlapping pain conditions (COPCs) on pain among these two groups. DESIGN: This was a cross-sectional study, based on an online survey. METHODS: Participants (aged 18+ years) completed a survey collecting pain diagnoses and symptoms assessing pelvic pain severity, pain interference, and pain impact. Independent sample t-tests, chi-square, and multiple linear regression models were employed to analyze group differences in pain symptomatology and COPCs. RESULTS: Of the 525 respondents with CPP, 25% (n = 133) reported having endometriosis. Women with endometriosis were younger at the onset of pelvic pain, relative to women without endometriosis (p = 0.04). There were no differences in age, race, ethnicity, or duration of pelvic pain between women with and without endometriosis. Women with endometriosis reported higher pelvic pain severity (+0.8, 95% CI = 0.4-1.1), pain interference (+5.9, 95% CI = 2.4-9.3), and pain impact (+1.9, 95% CI = 0.8-2.9). Endometriosis was associated with a higher number of COPCs (p = 0.003), with 25% (n = 33) of women reporting ⩾3 overlapping pain conditions compared with 12% (n = 45) of those without endometriosis. Women with endometriosis had a higher frequency of fibromyalgia (p < 0.001), chronic fatigue syndrome (p < 0.001), and temporomandibular disorder (p = 0.001). The number of COPCs was associated with higher pain severity, interference, and impact, independently of endometriosis. CONCLUSION: Women with endometriosis experienced higher levels of pain-related burden and COPCs compared with those without endometriosis. Pain intensity, interference, and impact increased with a higher number of pain conditions regardless of endometriosis presence.

Presence of endometriosis and chronic overlapping pain conditions negatively impacts the pain experience in women with chronic pelvic­abdominal pain: A cross-sectional surveyThe presence of endometriosis was associated with a higher number of chronic overlapping pain conditions (COPCs) and greater pain symptomatology, while a greater number of COPCs corresponded to increased pain burden among women with and without endometriosis. These findings underscore the need for a more comprehensive assessment of endometriosis that addresses the full experience of the disease, including its comorbidities. A greater characterization and measurement of COPCs has the potential to facilitate the development of tailored interventions for individuals with pain comorbidities, thereby contributing to improved clinical care strategies for endometriosis-related pain.

A pilot feasibility multicenter study of patients after excision of endometriosis.

OBJECTIVE: To serve as a pilot feasibility study for a randomized study of excision versus ablation in the treatment of endometriosis by (1) estimating the magnitude of change in symptoms after excision only at multiple referral centers and (2) determining the proportion of women willing to participate in a randomized trial. METHODS: We performed a multicenter prospective study of women undergoing excision for endometriosis (Canadian Task Force class II-3) at Duke University Center for Endometriosis Research & Treatment (currently the Saint Louis University Center for Endometriosis), Center for Endometriosis Care, Northshore University Health System, Memorial University (Canada), and Florida Hospital. The study comprised 100 female patients, aged 18 to 55 years, with endometriosis-suspected pelvic pain. The intervention was laparoscopic excision only of the abnormal peritoneum suspicious for endometriosis. The main outcome measures were quality of life, pelvic pain, dysmenorrhea, dyspareunia, and bowel and bladder symptoms. RESULTS: The mean follow-up period was 8.5 months. Excision of endometriosis showed a significant reduction in all pain scores except bowel symptoms, as well as significant improvement in quality of life. Of the patients, 84% were willing to participate in a randomized study. CONCLUSIONS: Quality of life is a needed primary outcome for any randomized study comparing excision versus ablation. A multicenter comparative trial is feasible, although quality assurance would have to be addressed. Patients were willing to be randomized even at surgical referral centers.

Time to move beyond surgical classification systems for endometriosis.

Endometriosis is a common condition associated with chronic pelvic pain and infertility. Its pathogenesis is poorly understood, diagnosis relies on laparoscopy, and staging is based on extent of disease. Unfortunately, the current staging systems do not correlate well with pain severity and impact, nor do they predict prognosis, i.e., treatment success and recurrence of disease. In this article, we discuss the strengths and limitations of current staging systems and propose modifications that will enable better classification systems to be developed in the future.

Vaginal laser therapy for gynecologic conditions: re-examining the controversy and where do we go from here.

Despite significant controversy, vaginal laser therapy continues to be used for treatment of many gynecologic and pelvic conditions including vaginal atrophy, vaginal dryness, dyspareunia, urinary incontinence and pelvic pain. This commentary reviews the controversy surrounding vaginal laser therapy and summarizes the important distinction between ablative and non-ablative vaginal lasers. While much research is still needed, the article describes what is important for healthcare professionals to know before making the decision to integrate this technology into their clinical practice.

Transvaginal Photobiomodulation Improves Pain in Women with Pelvic Muscle Tenderness and Interstitial Cystitis/Bladder Pain Syndrome: A Preliminary Observational Study.

PURPOSE: Interstitial Cystitis/ Bladder Pain Syndrome (IC/BPS) is characterized by pelvic/bladder pain, associated with pelvic muscle tenderness, urgency, frequency, and dysuria. Prior studies show that transvaginal photobiomodulation (TV-PBM) reduces pain in women with chronic pelvic pain (CPP). Our objective was to obtain preliminary data on treatment effect and adherence, in women with IC/BPS who selected TV-PBM therapy for management of pelvic pain. MATERIALS AND METHODS: Before-and-after observational cohort study of women with IC/BPS who received TV-PBM in 17 US practices. Pain was measured using a 0-10 numeric rating scale (NRS). The primary outcome was a minimal clinical important difference (MCID); reduction of overall pelvic pain severity by ≥2 NRS points from baseline compared to after 8 treatments. Cohen d coefficient measured effect size (low effect size d<0.2, medium 0.20.8). RESULTS: Of 140 patients with IC/BPS who self-selected to start TV-PBM therapy, 89.3% (n=125) completed 4 treatments and 59.3% (n=83) completed 8. Improvement ≥1 NRS point was reported by 73.5% (n=61) and meaningful improvement (≥2 points) was reported by 63.9% (n=53) after 8 treatments. In this group, patients with severe / moderate pain decreased from 83.1% (n=44) to 38.5% (n=20); p<0.001. Pain levels decreased as follows: overall pelvic pain MCID=-2.7, d=1.07, pain with urination MCID=-2.6, d=1.0; pain with exercise MCID=-2.6, d=0.91, pain with intercourse MCID=-2.5, d=0.82. CONCLUSION: In real-world clinical settings, 2/3 women with IC/BPS who opted to undergo TV-PBM therapy reported significant decrease in pelvic pain and dysuria. These findings are promising; however, controlled studies are needed.

Transvaginal Photobiomodulation for the Treatment of Chronic Pelvic Pain: A Pilot Study.

Background: Chronic pelvic pain (CPP) is a common and debilitating condition that affects millions of U.S. women. Most treatments are ineffective and innovative new therapies are desperately needed. Large, controlled studies show that photobiomodulation (PBM) can reduce pain in patients with other chronic pain conditions, such as low back pain, neck pain, and fibromyalgia. The objective of this pilot study was to determine if transvaginal PBM (TV-PBM) can reduce pain in women with CPP. Methods: We conducted a before and after, observational, pilot study. Patients completed the Short Form-McGill Pain Questionnaire (SF-MPQ) at baseline, 1 week, 3 months, and 6 months after nine treatments of TV-PBM. Clinicians completed the Clinical Global Impression Scale (CGI) assessing patient illness severity at the same time. Wilcoxon rank-sum t-tests and effect size using Cohen's d coefficient (low effect size if d < 0.2, medium if 0.2 < d > 8, and high if d > 0.8) was used to measure degree of pain improvement, which was also considered clinically significant if pain reduction was >30%. Results: Thirteen women completed 9 treatments, and 10 women were successfully followed to 6 months. At baseline, the mean SF-MPQ score was 19.7 (standard deviation [SD] ± 5.9). Compared with baseline, 60% improved; the mean SF-MPQ score decreased to 10.0 (SD ±7.5, p = 0.004, d = 1.6) at 1 week after treatment, to 9.7 (SD ±7.9, p = 0.005, d = 1.7) at 3 months, and 8.2 (SD ±8.1, p = 0.002, d = 1.9) at 6 months. Conclusion: Transvaginal PBM provided significant and sustained pain relief to women with CPP up to 6 months. Further controlled studies are needed to confirm these findings, however, in this initial pilot, TV-PBM shows promise.

An observational cohort study of pelvic floor photobiomodulation for treatment of chronic pelvic pain.

Aim: This research is the first to evaluate the effectiveness of trans-vaginal photobiomodulation therapy (TV-PBMT) for chronic pelvic pain. Materials & methods: Observational analysis of 128 women, undergoing TV-PBMT for chronic pelvic pain. Minimal clinically important difference, defined as ≥2-point drop on a 0-10 numeric pain rating scale (NPRS), and effect size Cohen d coefficient, was calculated over nine treatments for overall pain, and pain with activities. Results: Compared with baseline, 64.5% of women showed improvement in overall pain, pain with bowel movement, intercourse, exercise, urination, sitting and vulvar pain (minimal clinically important difference = -2.4, -2.0, -2.4, -2.1, -2.1, -2.0, -3.1; d = 0.9, 0.7, 0.9, 0.7, 0.7, 0.7, 0.9) by treatment 9. Conclusion: In this cohort, TV-PBMT resulted in improvement of pelvic pain without serious adverse events.

Lay abstract Low-level laser is a therapy that can help pain, but this type of treatment has not been available to women with chronic pelvic pain because traditional laser devices cannot access the pelvic structures. In this research we studied a novel low-laser device that can be used in the vagina, to treat pain arising from pelvic organs and muscles. Our preliminary research shows that this approach significantly reduced pelvic pain, and pain with activities such as exercise, urination, bowel movements and intercourse, in two-thirds of women who completed the therapy.

Paracervical Block or Uterosacral Ligament Infiltration for Benign Minimally Invasive Hysterectomy: A Systematic Review and Meta-analysis.

OBJECTIVE: The aim of this study was to estimate the efficacy of preemptive paracervical block or uterosacral ligament infiltration in reducing postoperative pain and opioid consumption after benign minimally invasive hysterectomy. DATA SOURCES: We searched MEDLINE, Cochrane Library, Embase, ClinicalTrials.gov, and Google Scholar from inception until February 2020. METHODS OF STUDY SELECTION: We identified randomized placebo-controlled trials assessing the primary outcome of pain and opioid consumption after paracervical block or uterosacral infiltration in benign laparoscopic, vaginal, or robotic hysterectomy. Two investigators evaluated studies for risk of bias and quality of evidence. TABULATION, INTEGRATION, AND RESULTS: We reviewed 219 abstracts; 6 studies met the inclusion criteria: 3 using paracervical block (2 vaginal and 1 laparoscopic) and 3 using uterosacral ligament infiltration (all vaginal). Two studies were included in the meta-analysis (both vaginal hysterectomy). Because of lack of numerical data, or comparison, the other 4 studies are reported in narrative form. Three controlled trials reported a moderate benefit from paracervical block up to 8 hours after vaginal and 4 hours after laparoscopic surgery. Meta-analysis could not be performed because of the lack of numerical data for pooling results or the lack of a laparoscopic hysterectomy comparison group. Three trials reported that uterosacral infiltration decreases pain up to 6 hours after vaginal hysterectomy, and meta-analysis pooling the results of 2 of these studies demonstrated improvement in pain up to 4 hours on a 0- to 100-mm visual analog scale for pain (-19.97 mm; 95% confidence interval, -29.02 to -10.91; P < 0.000). Five trials reported a moderate reduction in cumulative opioid use within 24 hours after vaginal surgery for both paracervical block and uterosacral infiltration. Meta-analysis was not performed for paracervical block because only 1 trial provided suitable data for pooling. Meta-analysis pooling the results of 2 trials of uterosacral infiltration demonstrated opioid consumption of 20.73 morphine milligram equivalents less compared with controls (95% confidence interval, -23.54 to -17.91; P < 0.000). CONCLUSIONS: There were a total of 6 randomized placebo-controlled studies evaluated in this study. Although a meta-analysis was unable to be performed for all studies because of lack of comparison groups or numerical data, there is evidence that preemptive uterosacral ligament infiltration may reduce postoperative pain and opioid consumption after vaginal hysterectomy. Our study does not allow us to make any substantive conclusions on the use of paracervical block in vaginal hysterectomy or the use of either type of injection in laparoscopic or robotic hysterectomy.

Impact of pain and nonpain co-morbidities on opioid use in women with endometriosis.

Aim: To evaluate impact of co-morbidities on opioid use in endometriosis. Patients & methods: This was a retrospective analysis of data obtained from the Symphony Health database (July 2015-June 2018), which contains medical and pharmacy claims information on 79,947 women with endometriosis. Relative risk (RR) of postdiagnosis opioid use and supply duration associated with baseline co-morbidities were determined. Results: Women with endometriosis using opioids at baseline were 61% more likely to receive opioids postdiagnosis (RR: 1.61; 95% CI: 1.59-1.63). Risk of prolonged opioid supply postdiagnosis was highest for those with prolonged supply at baseline (RR: 21.14; 20.14-22.19), and was 1.32 (1.26-1.38) for patients with ≥1 co-morbidity, 1.37 (1.31-1.43) for pain co-morbidities and 1.07 (1.04-1.11) for psychiatric co-morbidities. Conclusion: Risk of opioid use after endometriosis diagnosis was greater in patients who used opioids before diagnosis. Risk of prolonged opioid use was greater if co-morbidities existed before diagnosis.